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And well, it's a great pleasure to be joined by people from the North American continent, Nicholas. Thank you so much. Um We mustn't, we mustn't forget as we said earlier that the first neurosurgical unit, French a hospital was in fact planned by the Americans and staffed by the Americans to begin. So well. Welcome, Professor Nick Theodore. Thank you, Professor. Uh It's a great, great honor to be here. I, I realize that this evening I'll be sitting at the Memphis table and feel like an honorary Memphis graduate because I started my residents at the Naval Hospital, Bethesda Maryland and at the time, Jt Robertson, who you all know, came through as a navy reservist. And he looked at me, he said, you're never gonna learn to operate here. You have to go to Bristol. And uh he, he helped set up a rotation here, which was literally transformational in, in my career. And, you know, as a, as a spine surgeon, I will, I will say that, you know, it is uh it's interesting because, you know, oftentimes Malign, but when I was here, I realized that everybody did spine and I learned really a tremendous amount uh in my training here across the gamut from brain spine surgery. And really along the way, picked up some things I think that that really helped define my career. So it really is, it's very humbling to, to be here. And when I, when I arrived, obviously, these were the, the individuals that were really instrumental in my training here. I showed up on, uh American Thanksgiving day raining. My wife was in tears because there was nothing to eat. And Mister Sandman and his wife invited us over for dinner. And really it turned out to be the some of the best six months of my, of my training. While I was here, I, you know, I was really exposed to very cutting edge thinking. So uh the ability to incorporate technology into the operating room really has been a calling card for me and really at my life long passions. And while I was here, really exposed to the very early aspects of image guided surgery. And one of the things that struck me was that nobody's looking at the patient, everybody's looking at the screen. It did give us information obviously that we had, but there was an attention deficit and this was in spine surgery as well. And we saw that we were as we did uh spine surgery and image guided spine surgery. Again, we're all looking at uh looking at that screen. And when we talk about image guidance in the brain obviously, it's like GPS. We want to be where we want to be at any given time. We want to know where we are. Um, in the spine surgery. Obviously, the whole issue is accuracy and precision. We want to have high accuracy and high precision. We want to hit that mark every single time we want to be able to be where we are. And it really becomes important when doing something as mundane is placing pedicle screws. And when you look at the literature, about 9% of the time, we're not as good as we think we are. We have an errant screw most of the time. Thankfully, that doesn't hurt the patient. But again, as we start looking at this, we realize that we can probably do better in sponsors than we have. Interestingly, whereas in brain surgery, now every case is done with image guidance. Okay. So it was here in 1995 just starting to, to see this technology evolves. But now there isn't a case in North America. I would argue the UK where deep brain tumor is done without image guidance. It just doesn't happen in spine surgery though there was a disconnect and part of that disconnect occurred because of the ability to register to the spine. And that, that was a difficult proposition. And because of that, that we lost a generation of surgeons and spine surgeons utilizing image guidance. I was here the year Kieran Bolger came and again, we have these discussions, but it was very cumbersome, I would say right now, we have a very unique opportunity with advent with uh improvements in imaging surgery and robotics. We've got image guided surgery, we have surgical robotics and, and now we have this nexus of image guided surgical robotics. And I think that this is uh you know, this is where the future is going to be. At least I, I believe in spine surgery. I came back to Phoenix and, and we was able to do endoscopic surgery. Part of the problem there was holding the endoscope for eight hours. This is Curtis Dickman who's one of my mentors who used just it was a positioning device to hold a robotic arm. So I didn't have to hold that endoscope for eight hours while he did a thoracic disk that was 25 years ago. And now all of a sudden robotics is really has kicked in, I think, and I think we'll be here to stay in our field. Why would we adopt that? What, what we're looking for is increasing procedural accuracy. We want to decrease radiation. We don't want to have to be exposed to radiation and we have the opportunity to plan our surgery. So, I mean, as a, as a big racing enthusiasts, if you look back in 1960 for NASCAR, you see that this is the way we did things the car would pull in and uh they would be getting some gas, having some engine work that needs to be done to fix that. Can you fix the fender there? Sure. We'll go ahead and repair the fender for you. We'll kick that in for you and then we'll get back on. So it was 1960 for 1980 for where my mentor Voelker Sontag was first starting to do pedicle screws and were first exposed to spinal instrumentation that carried on while I was here. We had to know the anatomy. We always have to know the anatomy, but we make these enormous incisions. You have to palpate everything and look. And then we, we fast forward to 2016, a much different story. Right now, the car pulls in and within 12 seconds, you're able to completely change all four tires, change the oil. And I would argue that now we're in that point in in spine surgery. This is now we're able to literally in the beginning of a case for a minimally invasive case, do four pedicle screws in about five or six minutes, which again, I would never even conceive of a few years ago. And this really, this idea, this is technology that I developed over the past 20 years, came from here. Again, speaking with the surgeons here and understanding the ability to take technology from an idea into the operating room. So this is the lab in Phoenix in 2020 or 21 01, I should say enough to date myself next life. And uh you know, we could see basically what does it look like. What does the surgical robot look like for spinal surgery? How how do you design something that you can actually bring in? And this is our first iteration here, basically six axis of rotation, but fully image guided you plan the procedure you want to do. The robotic arm will execute and far as finding where you want. So just like in the brain, touching the brain and know where we are. But automating that process for us and this is 2012. So about 12 years into the project, we're in the in the lab with the cadaver. And you know, this was the aha moment that we could actually take this big hunk of metal, roll it into the lab, take a picture of the of the spine and then look at uh realized that we could nail the pedicle uh very accurately in a very short amount of time percutaneously. So this really to me was was transformational. And I see this uh technology being adopted. It's being used here in the UK now and it allows you to have just not just image guidance but also the robotic aspects of planning surgery, being able to plan what you're doing. The residents were worried that we're gonna take their job away from them. But at the end of the day, it wheels in, you can put your screws in, if we're doing a thoracic case or scoliosis case. Now, a lot of the upper screws will put in percutaneously. And then, you know, utilizing either intra operative CT or what I use frequently as preoperative ct, the machine will give you feedback if you're accurate. And if something is skiving or moving the most important thing, especially if you're doing something percutaneously is understanding where you are at any given time. But if there's a uh you know, we talked about in the brain, we all know about brain shift. You open up the CSF moves the brain will, will sag your navigation is off in the spine. We're putting a screw and we don't want that there's a shift per se. But we hate, we do know if something happens with navigation. This is 2017. We finally got FDA approval. Did the first case on October 4th in the operating room were about 50 people. The dean of the medical school, the presidente, my department chairman and everybody's crowding around and I pushed the button. I said go to L4 and the robot goes to L5 and I looked down and I pushed all four again. It goes to all five sweats beating down my face. My fellow says, are you okay? I said no, I'm about ready to faint because if this doesn't work, I've just spent 20 years of my life doing for nothing. Turns out our incision was off. The robot was perfect. So again, near, near cardiac death at that point, next slide, you know, we're, we're now able to, to do things uh next slide for sex or, you know, this is a case that was done in the middle of the night. Um uh police officers involved in a high speed motor vehicle accident. The interesting thing is again, it's not just a 9 to 5 thing. You uh they were now able to, to pull this out in the middle of the night to help us percutaneously fixed patient's with terrible injuries like this. Um And, and again, going into to fixing the spine, ultimately shaving down the blood loss, uh you know, increasing actually, now we're able to do these operations in a fraction of the time. And, and now demonstrating that are accuracy has significantly increased the use when things start off though. It's not always fast, there's always a learning curve. This next, this is a case of a hemangioma uh that we intra operatively embolize with onyx. At the time, we were able to use the robot to put screws in and then also cannulate the tumor and then embolized directly uh with onyx uh during the case, which is actually great because as we all know that these hemangiomas can be uh very bloody case. This is the post operative result. We're using it in the cervical spine now as well. And this is a case of an individual had a hangman's fracture from, from bodysurfing and also a central cord injury. So again, if we, if we normally would fix, see 12 and take away the a significant amount of motion for this patient were able now to directly cannulate the pars and, and fix that fracture directly without having to, to lose a motion segment at C 12. And this is uh this has been great. There are cranial applications. I know Steve Gill will tell us about that. Ultimately, you know, our precision now is a little bit different. So it used to be, are we in that we get an X ray or ct after surgery would say, are we in the pedicle? Okay. That's a very easy question. Now, not only in the pedicle, but how are we based on our plan? So now we can take a plan uh and then over like it to where we place the screw and have three dimensional understanding of how accurate we are, which is again raising the bar and what we do, there's a learning curve to everything that you do in surgery. And we certainly with any technology and the, and the reality is that we found that out now we've shaved off in our first series about 4.5 minutes a case to the point. Now we're getting into, uh you know, doing a single level fusion in an hour or less, which is, which has been great. And I think this technology, what you're gonna see is that ultimately we start doing more and more. So we're starting to think about how do we do cutting, how we do drilling, how we do other aspects of the procedure. Uh not just putting the screws in and I think that's going to be coming very shortly and I think that's the knee part. So we've got, now in the lab were able to program the robot to help us make cuts uh to uh you know, in, in uh in bone plan on what we know. So it's not just putting screws in, but now doing the decompression other more elegant parts of the case. But I think the take home message is that it's all about inspiration and it's all about exposure and, and again, it's want to thank Professor Coke. Um You know, Mr Nelson Santa Mint Gill Bulger, everybody that was here when I was here because it really transform my current and really, I think was an amazing aspect and hearing these talks this morning has been very humbling and understanding exactly this tradition. So I feel honored to have been here at a, at a great time and, and thank everybody for their time and attention.
